Copd Follow Up
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COPD Patient Evaluation Date Time ROS
WNL See HPI
Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro
Endo Heme/lymph
Allergy/Immun Psych
History
Patient Name
DOB
MRN
Chief Complaint or Reason For Visit
PMSH Social Family
Physical Exam Checkedwww.e-medtools.com box indicates findings are within normal limits
Resp CV
Musc
Lymph
Extrem Skin
Current New Short-acting beta agonist
Neuro
Oral steroids Antibiotics Nicotine replacement Buproprion Nicotine receptor blocker CPAP
BiPap
Vital signs
Temp
Pulse
BP
RR
Tone Gait Digits No rashes, ecchymoses, nodules, ulcers
<70%
Moderate
50-79%
< 70%
Severe
30-49%
< 70%
Very Severe
<30%
< 70%
Pulse ox at rest
With exercise
______ # Packs X ______ # Yrs Never smoked Quit Unwilling to quit Willing to consider quitting Quit, but resumed smoking Willing to quit within 1 month
Orientation www.e-medtools.com Affect
Impression and Plan
Tests to be ordered Bronchoscopy Pulmonary Function Testing Methacholine challenge 6 Minute Walk Test Sleep study CXR Chest CT without contrast Echocardiogram with Bubble study PA pressures Cardiopulmonary Stress Test Pulmonary Rehabilitation Surgical eval for lung reduction Bone density evaluation Pneumococcal vaccine Influenza vaccine Labs
www.e-medtools.com
www.e-medtools.com
Education and Instruction
Oxygen Therapy Follow up
Signature CODE STATUS: Data Reviewed
t 70%
www.e-medtools.com
COPD Therapy
>80% >79%
Nasal mucosa Dentition Oropharynx Mallampati I II III IV Palpation www.e-medtools.com Thyroid No JVD Auscultation Percussion Respiratory effort Palpation Chest wall Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema No palpable masses No hepatosplenomegaly No hepatojugular reflux Tobacco Use Lymph nodes
Neck
At risk Mild
ENT
GI
FEV1 FVC
Alert
Long-acting beta agonist Long acting anticholinergic Theophylline
FEV1
General
Inhaled steroid
Symptom Severity and Frequency
Asymptomatic with usual activity Symptomatic with usual activity Symptomatic with minimal activity Symptomatic at rest Recent antibiotic use Recent oral steroid use Recent ED visits Recent hospital admissions Weight loss/Decreased appetite
No changes See HPI
Allergies
HPI
Full code Do Not Attempt Resuscitation
Smoking cessation Peak flow meter use Inhaler use Importance of vaccinations Risks of alcohol, narcotics and BZD Medication side effects Supplemental oxygen for air travel US CT
ER Notes Old Chart EMS Note ECG Nursing Notes & Vitals log Labs X Rays MRI ER MD HCPOA Primary Care MD Case Management Social Worker Pharmacy
Care Coordinated With
©MB and RR 2006, 2007
www.e-medtools.com
WNL See HPI
Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro
Endo Heme/lymph
Allergy/Immun Psych
History
Patient Name
DOB
MRN
Chief Complaint or Reason For Visit
PMSH Social Family
Physical Exam Checkedwww.e-medtools.com box indicates findings are within normal limits
Resp CV
Musc
Lymph
Extrem Skin
Current New Short-acting beta agonist
Neuro
Oral steroids Antibiotics Nicotine replacement Buproprion Nicotine receptor blocker CPAP
BiPap
Vital signs
Temp
Pulse
BP
RR
Tone Gait Digits No rashes, ecchymoses, nodules, ulcers
<70%
Moderate
50-79%
< 70%
Severe
30-49%
< 70%
Very Severe
<30%
< 70%
Pulse ox at rest
With exercise
______ # Packs X ______ # Yrs Never smoked Quit Unwilling to quit Willing to consider quitting Quit, but resumed smoking Willing to quit within 1 month
Orientation www.e-medtools.com Affect
Impression and Plan
Tests to be ordered Bronchoscopy Pulmonary Function Testing Methacholine challenge 6 Minute Walk Test Sleep study CXR Chest CT without contrast Echocardiogram with Bubble study PA pressures Cardiopulmonary Stress Test Pulmonary Rehabilitation Surgical eval for lung reduction Bone density evaluation Pneumococcal vaccine Influenza vaccine Labs
www.e-medtools.com
www.e-medtools.com
Education and Instruction
Oxygen Therapy Follow up
Signature CODE STATUS: Data Reviewed
t 70%
www.e-medtools.com
COPD Therapy
>80% >79%
Nasal mucosa Dentition Oropharynx Mallampati I II III IV Palpation www.e-medtools.com Thyroid No JVD Auscultation Percussion Respiratory effort Palpation Chest wall Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema No palpable masses No hepatosplenomegaly No hepatojugular reflux Tobacco Use Lymph nodes
Neck
At risk Mild
ENT
GI
FEV1 FVC
Alert
Long-acting beta agonist Long acting anticholinergic Theophylline
FEV1
General
Inhaled steroid
Symptom Severity and Frequency
Asymptomatic with usual activity Symptomatic with usual activity Symptomatic with minimal activity Symptomatic at rest Recent antibiotic use Recent oral steroid use Recent ED visits Recent hospital admissions Weight loss/Decreased appetite
No changes See HPI
Allergies
HPI
Full code Do Not Attempt Resuscitation
Smoking cessation Peak flow meter use Inhaler use Importance of vaccinations Risks of alcohol, narcotics and BZD Medication side effects Supplemental oxygen for air travel US CT
ER Notes Old Chart EMS Note ECG Nursing Notes & Vitals log Labs X Rays MRI ER MD HCPOA Primary Care MD Case Management Social Worker Pharmacy
Care Coordinated With
©MB and RR 2006, 2007
www.e-medtools.com
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